A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

Place a pillow under the client's head.

Gently restrain the client's arms.

Administer a muscle relaxant.

Insert a tongue blade.

Answer and Explanation

The Correct Answer is A

A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.

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Correct Answer is C

Explanation

A. A client who is postoperative and has a Jackson-Pratt drain. A Jackson-Pratt drain is a routine postoperative device used to prevent fluid accumulation. Unless there are signs of excessive drainage, infection, or blockage, this client does not require immediate attention.
B. A client who is scheduled for surgery in 2 hr. While preoperative preparation is important, it is not the most urgent concern. This client can be attended to after addressing more pressing clinical issues, such as potential hypertensive complications.
C. A client whose blood pressure is 160/90 mm Hg and reports a headache. A significantly elevated blood pressure with a headache may indicate a hypertensive crisis, which increases the risk of stroke or other complications. This client should be assessed immediately to determine the severity and need for intervention.
D. A client who is postoperative and reports intermittent nausea. Nausea is a common postoperative symptom and can often be managed with antiemetics and dietary modifications. It does not pose an immediate life-threatening risk compared to possible hypertensive emergencies.

A. Increased iron level B. Increased erythrocyte sedimentation rate C. Decreased platelets D. Decreased hemoglobin

Correct Answer is B

Explanation

A. Increased iron level: Iron levels typically decrease during infection due to the body's inflammatory response. The liver sequesters iron to limit bacterial growth, leading to lower serum iron levels. An increased iron level is not an indicator of infection and may instead be associated with conditions such as hemochromatosis or excessive iron supplementation.
B. Increased erythrocyte sedimentation rate: The erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and infection. When an infection occurs, inflammatory proteins cause red blood cells to clump together and settle faster, leading to an increased ESR. A high ESR can indicate an ongoing infection, autoimmune disorder, or chronic inflammatory condition.
C. Decreased platelets: Platelets, or thrombocytes, are involved in blood clotting and do not serve as a primary indicator of infection. While severe infections, such as sepsis, can lead to thrombocytopenia (low platelets) due to disseminated intravascular coagulation (DIC), this is not a common finding in routine infections.
D. Decreased hemoglobin: Hemoglobin levels reflect the oxygen-carrying capacity of red blood cells and are not directly linked to infection. While chronic infections and inflammatory conditions can contribute to anemia of chronic disease, an acute infection typically does not cause a sudden drop in hemoglobin.

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